RESP: asthma

Question 2

Presentation of asthma:

a) Symptoms?
b) Signs?

Answer 2

a) Symptoms: 
Wheeze
Dyspnoea
Cough (may be nocturnal)
Chest tightness
Diurnal variation (symptoms often worse in the morning)

b) Signs:
Tachypnoea
Hyperinflated chest
Hyper-resonance on chest percussion
Decreased air entry (sign of severe illness: silent chest)
Wheeze on auscultation

Question 3

Investigations for suspected asthma?

Answer 3

1. Peak flow: variability >20%
2. Fractional exhaled nitric oxide (FeNO): >40 ppb in adults or >35 ppb in children
3. Spirometry with bronchodilator reversibility: FEV1/FVC < 0.7 (obstructive spirometry). Improvement of FEV1 > 12% after bronchodilator therapy is diagnostic
4. Bloods - FBC, U+Es, ABG
5. CXR

Question 4

Non - pharmacological management of asthma? (not an acute attack)

Answer 4

Smoking cessation
Avoidance of precipitating factors (eg. known allergens - dust, animal hair, cold air etc)
Review inhaler technique

Question 5

Pharmacological management of asthma? (not an acute attack)

Answer 5

Step 1: short-acting inhaled B2-agonist (eg. Salbutamol)
Step 2: add low-dose inhaled corticosteroid steroid (ICS)
Step 3: Long-acting beta-2 agonists (e.g., salmeterol) or maintenance and reliever therapy (MART)
Step 4: Increase the inhaled corticosteroid or add a leukotriene receptor antagonist (e.g., montelukast)
Step 5: Specialist management (e.g., oral corticosteroids)

(modified 19/2/24- info from BTS guidelines and Z2F)

Question 6

Investigations for acute asthma attack?

Answer 6

ABG: type 2 respiratory failure (low PaO2 and high PaCO2) is a sign of a life-threatening attack.

Routine blood tests (including FBC, CRP): to look for precipitating causes of an asthma attack, such as an infection.

Chest x-ray: to exclude differentials and possibly identify a precipitating infection.

Question 7

Management of acute asthma attack?

Answer 7

• ABCDE - Ensure a patent airway
• Ensure oxygen saturations of 94-98%, ABG if O2 sats <92%
• Nebulisers: Salbutamol 5mg (can repeat after 15mins).
• Steroids: oral Prednisolone 40mg STAT or IV Hydrocortisone (if PO not possible)

Question 8

Differential diagnosis for asthma?

Answer 8

Bronchiectasis 
COPD 
CF 
Foreign body aspiration (especially in children)
GORD 
HF 
Interstitial lung disease 
Lung cancer 
Pertussis

Question 9

Characteristics of asthma? i.e. what is it?

Answer 9

Chronic inflammation disease of the airways
Obstructive but reversible (spontaneously or w treatment)
Increased airway responsiveness (i.e. narrowing) to variety of stimuli.

Question 10

Pt has a wheeze. What are most likely/common differentials?

Answer 10

Acute asthma exacerbation
Bronchitis - bacterial or viral

Less common:
Pulm oedema 
PE
GORD
Allergy 
Hyperventilation
Cardiac disease 
Churg-Strauss syndrome

Question 11

Define MILD asthma exacerbation based on:

1) PEFR %

2) features of severe asthma

Answer 11

1) >75%

2) no features of severe asthma

Question 12

Define MODERATE asthma exacerbation based on:

1) PEFR %

2) features of severe asthma

Answer 12

1) 50-75%

2) no features of severe asthma

Question 13

Define SEVERE asthma exacerbation based on:

1) PEFR %

2) features of severe asthma

Answer 13

1) 33-50%
2) Cannot complete sentences in one breath
RR>25
HR>110

(ANY ONE OF THESE PRESENT = SEVERE ASTHMA ATTACK)

Question 14

Define LIFE THREATENING asthma exacerbation based on:

1) PEFR %

2) features of severe asthma

Answer 14

1) <33%
2) Sats<92% or ABG pO2<8kPa
Cyanosis, poor response effort, silent chest
Exhaustion, confusion
Hypotension, arrythmias
normal pCO2

Question 15

Define NEAR FATAL asthma exacerbation based on features of severe asthma

Answer 15

RAISED pCO2

Question 16

Management of SEVERE (PEFR 33-50%) asthma attack?

Answer 16

Same as acute asthma attack

• ABCDE - Ensure a patent airway
• Ensure oxygen saturations of 94-98%, ABG if O2 sats <92%
• Nebulisers: Salbutamol 5mg (can repeat after 15mins).
• Steroids: oral Prednisolone 40mg STAT or IV Hydrocortisone (if PO not possible)

PLUS:

• Nebulised ipratropium bromide 500micrograms
• back to back salbutamol if needed

Question 17

Management of LIFE THREATENING (PEFR <33%) asthma attack?

Answer 17

Same as acute asthma attack PLUS

• urgent ITU or anaesthetist assessment
• Urgent portable CXR
• IV aminophylline
• Consider IV salbutamol if nebuliser route is ineffective.

Question 18

Criteria for safe asthma discharge after exacerbation?

Answer 18

PEFR >75%
Stop nebulisers 24hrs before discharge
Inpatient asthma nurse review to reassess inhaler technique and adherence
Provide PEFR meter and written asthma action plan
At least 5 day course of oral prednisolone
GP follow up within 2 working days
Resp clinic follow up within 4 weeks
Psychosocial factors considered before discharge

Question 19

Differentials of eosinophilia?

Answer 19

Airway inflammation = COPD or asthma 
Hayfever/allergies 
Multiple courses of abx for chronic infections 
Eosinophillic pneumonia 
Parasites 
Lymphoma 
SLE

Question 20

Asthma triggers?

Answer 20

Smoking 
Cold air 
Allergens - dust, pollen, pets
URTI - mainly viral
Occupational irritants
Pollution 
Drugs - aspirin, Bblocker
Food and drink - dairy, alcohol, orange juice
Stress

Question 21

How to manage chronic asthma?

Answer 21

Use BTS stepwise management guidelines
Assess and teach inhaler technique
Self management plans
Avoid triggers